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19 year old female with arm swelling. Steven Shackford, MD FACS 2006. You are called by a RN who staffs the UVM student health clinic about a 19 y/o female on the swim team who has developed RUE swelling. You should: Set the patient up for your next available appointment—10 days hence.

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19 year old female with arm swelling

19 year old female with arm swelling

Steven Shackford, MD FACS

2006

slide2

You are called by a RN who staffs the UVM student health clinic about a 19 y/o female on the swim team who has developed RUE swelling. You should:

  • Set the patient up for your next available appointment—10 days hence.
  • Have the patient elevate the RUE— call if swelling does not resolve.
  • Refer the patient to an orthopedist
  • See the patient today
slide3

You elect to see the patient today. She is a healthy

college athlete with no prior medical history. She relates that since swimming practice started she has noticed increased tightness in the RUE. The day you saw her was the first time that the arm was swollen. Exam reveals a swollen RUE with blue discoloration, some dilated veins on the chest wall and normal pulses. There is no palpable cord. You should:

a) Refer the patient to Hematology.

b) Admit to the hospital and start anticoagulation.

c) Get a venous duplex.

d) Get an arteriogram.

slide4

You get a venous duplex, which shows loss of respiratory phasing and strongly suggests obstruction. You should:

  • Admit the patient and start anticoagulation.
  • Get an arteriogram.
  • Refer the patient to Hematology.
  • Get a venogram.
slide6

Based on this venogram, you:

  • Admit the patient for anticoagulation
  • Refer to Medicine for admission and anticoagulation
  • Initiate lytic therapy
  • Admit patient for trans-axillary first rib resection.
slide7

Lytic therapy successfully opens the subclavian vein, but there is marked effacement at the point where the vein crosses the 1st rib. In the “stressed” position (arm extended over the head) the lumen completely disappears and the collaterals reappear. You now:

a) Tell the patient to stop swimming and give up her swimming scholarship.

b) Begin anticoagulation with heparin followed by coumadin and tell the patient to stop swimming and give up her swimming scholarship.

c) Begin anticoagulation with heparin and schedule her for a supra-clavicular 1st rib resection ASAP (this admission).

d) Begin anticoagulation with heparin and schedule her for a trans-axillary 1st rib resection ASAP.

slide8

You elect to proceed with a trans-axillary 1st rib resection, which goes well. Because of your suspicion that the patient may have chronic trauma to the vein from her swimming, you turn her supine and obtain a venogram (next slide)

slide9

First rib resected

Still has obstruction

SVC fills, but less intensely than

the vein

slide10

Intra-operatively, you decide to:

a) Quit and put the patient on coumadin.

b) Do a jugular venous turn-down to the distal subclavian vein.

c) Bypass the obstruction with 16mm ringed Goretex.

d) Attempt balloon angioplasty of the obstruction.

slide13

Postoperatively, she does well. You now:

  • Discharge her and tell her to follow up with the RN at the student clinic.
  • Discharge the patient on coumadin for 3 months.
  • Discharge the patient on coumadin and to see you in the office in a month for imaging.
history
History
  • Classical or common
    • Unusual strenuous effort
    • Repeated movements associated with work or athletics
  • Frequent
    • Old clavicle fracture with hypertrophic nonunion
    • Situational: back pack use, prolonged position
  • Uncommon
    • No contributing etiology
    • Think hypercoagulable/hypofibrinolytic state
clavicular fracture
Clavicular fracture
  • Fracture history is remote
  • Hypertrophic nonunion: otherwise asymptomatic
  • Intermittent obstructive symptoms not uncommon
  • Usually an active person
symptoms
Symptoms
  • ALL will have these to some degree
    • Acute > subacute > chronic
  • Swelling: 85-90%
  • Pain: 75-85%
    • Heaviness, fatigue, aching
  • Violaceous discoloration: 35-50%
  • Paresthesias: 5-10%
  • Coldness: 0-5%
signs
Signs
  • Swelling (not edema)
  • Violaceous discoloration
  • Dilated superficial collateral veins
  • Tender axillary cord
  • Normal motor exam
  • Normal sensory exam
    • May have allodynia
diagnosis
Diagnosis
  • Physical exam: suggestive
    • Objective confirmation needed
  • Duplex (not B-mode): lab dependent
    • Sensitivity: 75-100%
      • Limited by scanning window, nonocclusive thrombus
    • Specificity: 100%
  • Venography
    • Gold standard
    • Allows for potential endoluminal therapy
treatment rationale
Treatment Rationale
  • No treatment
    • Disability: 25% (Hughes E, Int Abs Surg 38:89, 1949)
    • Pulmonary embolism: 12-35%
      • Usually > 1 risk factor
      • Case fatality rate: 10%
    • SVC syndrome: reported rarely
    • Venous gangrene
      • 16 reported cases(Smith B, Ann Surg 201:511, 1985)
        • Amputation: 54%
        • Mortality: 31%
treatment continuum
Treatment Continuum
  • Dependent on acuity
  • Gangrene: med + surg
  • Acute: med + lytics +/- surg
  • Subacute: med +/- lytics +/- surg
  • Chronic: +/- med +/- surg
venous gangrene
Venous Gangrene
  • Limb threatening
  • Heparin bolus
  • Thrombectomy of all major branches
  • Esmarch wrap with vein open & proximal control
  • Coumadin: INR 3-4
treatment acute ue dvt
Treatment: Acute UE DVT
  • Early diagnosis imperative
    • Collaterals form:  lytic efficacy
    • Lytics for 24-72h
  • Arm elevation
  • Heparin bolus: ptt >2-3x control
  • Coumadin: INR 2-3 for 3 months
  • Interval stress venography
  • Timing of 1st rib resection
    • Varies: 1 day – 3months
slide32

axilla

lipoma

subclavian vein

chest wall

slide33

subclavianartery

brachialplexus

subclavian vein

anterior scalene (cut)

1st rib

slide37

UEDVT <10 days old

thrombolytics

success-no stenosis

success-stenosis

1st rib rsn

stress venogram

-

+

angioplasty

anticoag x 3 mos

1st rib rsn

anticoag x 3 mos

slide38

UEDVT > 10 days

anticoagulation x 3 months

symptomatic

stress venogram

obstructs with stress

obstructed

consider reconstruction

1st rib resection

summary
Summary
  • All UEDVT is secondary
    • Virchow’s Triad
  • UEDVT is under-diagnosed
  • Delay in treatment worsens outcome
  • Treatment depends on clinical presentation
    • Acute
    • Subacute
    • Chronic